Small Claims Form 3. 2 1 : Affidavit of Property Exempt from Execution In the Iowa District Court for County Plaintiff(s) (Name) (Name) vs. Defendant(s) (Name) (Name) Affidavit of Property Exempt from Execution (Iowa Code s ections 626.50 and 642.15) Small Claim No. 1. T his is an Affidavit pursuant to Iowa Code s ections 626.50 and 642.15 to inform the sheriff and creditors of income and property exempt from execution under Iowa law. This filing is not an A nswer or motion in this pr o c e eding. 2. The following are my (ou r) only sources of monthly income and are exempt from execution (check all that apply): Social Security $ Supplementary Security Income (SSI) $ Veterans benefits $ Alimony , support , or separate maintenance $ Other (any other source of income) $ Employment* $ *Under Iowa law, disposable earnings are exempt if less than $290/week, $580/every 2 weeks, or $1,257/month . 3. I (We) have $ in cash, checking, and savings. This money is deposits from the sources listed above. If there are deposits from others sources, they total $1000 or less . 4. I (We) own the following property, which is exempt from execution (check all that apply ) : Homestead ; Clothing, s uitcases, musical instruments, and household goods and furnishings with a total value of $7,000 or less ; Books, family Bibles, pictures, portraits, and paintings with a total value of $1000 or less ; Burial plots ; One shotgun and either one rifle or one musket ; Prescribed health aids ; A motor vehicle (list year and make) , , with equity of $7,000 or less ; Tools of trade or farm equipment, livestock, and feed with a total value of $10,000 or l ess ; Wedding or engagement rings with a total value of $5,000 or less, or wedding or e ngagement rings received at least two years before the date of this A ffidavit ; Other jewelry with a total value of $2,000 or less ; Small Claims Form 3. 2 1 , page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Cash value of life insurance of $10,000 or less if spouse, child, or dependent is b eneficiary ; Rental deposits, utility deposits, or rent paid in advance of $500 or less ; Qualified retirement funds ; Cash on hand , bank deposits, other deposi ts, and other personal property up to $ 1,000 . 5. I (We) will electronically file this original document using the Iowa Judicial Branch Electronic Document Management System (EDMS) at https://www.iowac ourts.state.ia.us/EFile , unless I (we) obtain an exemption from electronic filing requirements from the court. I (We) will provide a copy of this original document to The Sheriff of County . 6. If this original document is electronic ally filed, EDMS will serve copies on t he other party (ies) or on the attorney(s) for the other party(ies). The Notice of Electronic Filing will indicate if I (w e) must mail a copy to other party(ies). I (We) certify, under the penalty of perjury, that I (we) own all of the property listed on this A ffidavit and, to the best of my (our) knowledge, it is an accurate listing of my (our) exempt property. Date: Date: /s/ /s/ Filing Defendant or Attorney Second Defendant, if applicable Law firm, or entity for which filing is made, if applicable Law firm, or entity for which filing is made, if applicable Mailing address Mailing a ddress Telephone number Telephone number Email address Em ail address Ad ditional email a ddress, if applicable Additional email a ddress, if applicable Small Claims Form 3. 21, page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com